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Manitoba's Shock Trauma Air Rescue Society (STARS) helicopter air ambulance service is the only one of its kind in North America known to have been temporarily suspended because of concerns over patient safety.

And one U.S. expert says if the province imposes further dispatch restrictions on STARS following its review, it could essentially neuter the helicopter emergency medical service and create a potential barrier to patient care.

MELISSA TAIT / WINNIPEG FREE PRESS FILES

Flying conditions for helicopter ambulances are often marginal, but one expert says that's overlooked.

Tom Judge, executive director of LifeFlight of Maine, a non-profit hospital critical-care system that serves more than 40 hospitals in Maine and New England and provides helicopter response to accidents and medical emergencies in remote and island communities, said while the province was correct to suspend STARS, it must also accept that in emergency medicine, things go wrong -- especially in the confines of a helicopter.

"It's a tremendous amount of courage by the health authority and the provider to open the books when they have something that doesn't go as planned," Judge said. "Obviously, from the public's perspective, transparency is good.

"Not all that happens in medicine goes right, even with the best of intentions, and sometimes even with the best of care, patients do not do well. There's lots of preventable medical error, but there are some things where bad things just happen."

Judge, who's worked with STARS over the years, has also advised the U.S. National Transportation Safety Board (NSTB) on pre-hospital emergency medical services and is a member of the Federal Department of Transportation's national EMS advisory council. He was named the 2011 Program Director of the Year by the International Association of Air Medical Services.

In its review, the province must balance patient safety with the inherently unpredictable nature of emergency medicine, he said.

"In a time-critical world, time in the patients that we deal with is often as much an enemy as the actual disease process. Yes, sometimes we want more controls in the system, but how do we put those into the system without having more time get taken off? That becomes a problem for patients."

Manitoba Health Minister Erin Selby suspended the operations of STARS Dec. 2 after three critical incidents in less than a year, including the death of a female patient suffering from cardiac arrest three days earlier. Each of the incidents involved issues with intubation and proper delivery of oxygen.

The first occurred last February and involved an adult -- no details have been released. It resulted in six dispatch restrictions being placed by the province on STARS, including the type of patient the service could fly and the distance it could transport patients.

The second critical incident was last May, and involved two-year-old Morgan Moar-Campbell, who was being flown from Brandon on a STARS helicopter for tests following a seizure. The boy was in an induced coma and could not breathe on his own. When he landed in Winnipeg, it was discovered his breathing tube had become dislodged, depriving him of oxygen and leaving him severely brain damaged. His case is now the subject of a lawsuit.

The provincial review, which includes an external audit of 15 other cases involving STARS, continues, Selby said this week. Originally, officials said the expectation was STARS would resume emergency flights this month. In the meantime, the service conducts regular training flights.

Judge said those reviewing STARS must be mindful that to restrict the service further -- on top of the six dispatch restrictions already placed on STARS -- will impact patient safety.

"There's risk in both directions," he said. "There are certainly some patients, I would guess -- with this suspension now more than 30 days -- that probably could have benefited, or also had bad outcomes, and that's not being captured."

He also said there are "bad patient outcomes" in ground ambulances the public never hears about.

"There's an issue of opacity in medicine in general, I think, all over the world. There are ground ambulance accidents and there is lots of care that goes south... and no one even knows about. And that's a problem."

Vancouver writer Paul Dixon, who's written extensively on Canadian helicopter air ambulance systems for Helicopters magazine, said despite Manitoba's experience with STARS, the overall Canadian experience with helicopter emergency medical services is far superior to the experience south of the border.

"The short story is that Canadian operations in one word are safer," Dixon said. "With the exception of Quebec, all the helicopters used are large helicopters, or in the business they would be 'medium' helicopters. Twin-engine, they fly two pilots and almost universally the pilots are instrument-rated so they are capable at flying at night and in conditions that would ground a light helicopter."

Judge agreed.

"Canada has a much better record when it comes to the safety of medical helicopters," he said.

The U.S. has been plagued with fatal helicopter air ambulance crashes for the past decade.

Since then, there have been an additional 39 deaths and 19 injuries resulting from helicopter emergency medical services.

"They are almost universally operating single-engine aircraft (like a Bell 206) with a single pilot," Dixon said of U.S. helicopter air ambulances. "You've got one pilot, one nurse or paramedic and one stretcher patient and you're loaded to the brim."

They are also flying under the pressure of getting to an emergency scene quickly.

"The hero mentality, they call it," Dixon said.

The NSTB is pushing for better training of pilots, since many accidents happen at night. Crashes are also due to helicopters colliding with wires and flying in extreme weather. The NTSB has also recommended national guidelines be created for the selection of appropriate emergency transportation (ground or air) for urgent-care cases. Draft guidelines have been published in the journal Prehospital Emergency Care.

There have been crashes in Canada. Last May 31, an Ontario Ornge helicopter air ambulance, a Sikorsky S-76A on a night flight, crashed near Moosonee, killing two paramedics and both pilots shortly after takeoff. The crash may have occurred because in the darkness, the crew lost visual reference with the ground.

In March 2011, a B.C. helicopter air ambulance taking off from a road near Pitt Meadows almost crashed when its rotor blades cut into a telephone line. The pilot landed safely. No one was injured and the patient was loaded into an ambulance to be driven to hospital.

The main difference between the two countries is U.S. helicopter air ambulance services -- there are more than 600 -- are mostly private, for-profit companies. In Canada, all operators except for Quebec are in varying degrees publicly funded.

What's needed in both countries is to continuously push up the standards of care, but in a reasonable way, be it how patients are ventilated -- manual "bagging" versus monitored intubation -- to how each emergency flight is reviewed to prevent error and reduce risk, Judge said.

"But there's a cost to that. Every time we put a new standard of care in, there is a cost associated with it. We're always trying to balance the cost of getting it wrong with putting the standard in."

Dixon also said what's often overlooked is the vast majority of helicopter air ambulance flights are extremely stressful.

"The people they are generally flying are critically ill -- these aren't pleasure flights. And the conditions they are flying in are often marginal.

"People don't realize this. They just get fixated on the helicopter."

Comparison of helicopter ambulance services across Canada

MANITOBA

Operations were suspended Dec. 2 after three critical incidents -- including the death of a woman three days earlier -- in less than a year. Each of the incidents involved issues with intubation and proper delivery of oxygen.

FUNDING: The province and Shock Trauma Air Rescue Society (STARS) signed a 10-year agreement, worth $10 million per year, in February 2012 for the non-profit, Alberta-based organization to provide helicopter air ambulance services in southern Manitoba. STARS is also funded through corporate, community and individual donations. In Manitoba, fundraising, including a lottery, is expected to raise 25 to 30 per cent of the service's $10-million annual costs.

ON BOARD: Each crew comprises two pilots, a critical-care nurse and a critical-care paramedic. An emergency physician trained in pre-hospital care and transportation is also available by telephone for every emergency response and travels in the helicopter when medically necessary.

AHEAD: The province said two years ago it would build a helicopter landing pad atop the new seven-storey, $39-million diagnostic imaging centre being built at the Health Sciences Centre. A value-for-money audit on the STARS agreement by Manitoba's auditor general, Carol Bellringer, is to be released early this year.

Here's what's happening in other jurisdictions:

BRITISH COLUMBIA

The BC Ambulance Service contracts helicopter services with two private companies, Helijet International and CC Helicopters Ltd., as part of its provincewide critical-care transport program. Two helicopters are based in Vancouver and there is one each in Prince Rupert and Kamloops.

There have been no critical incident reviews.

ON BOARD: Each base is staffed with dedicated critical-care paramedics with the exception of Prince Rupert, which is staffed with on-call primary-care paramedics.

FUNDING: In 2012-13, the publicly funded BCAS spent $55.1 million for the aircraft, ambulances, personnel, training and fuel in support of the transport program. The annual cost of the four helicopters is estimated at about $15 million.

AHEAD: B.C. auditor general John Doyle said in a report last year the province's air ambulance service was weak in measuring the quality, timeliness and safety of its patient care. He also said staffing shortages mean lesser-skilled paramedics were sent to emergencies in pairs because higher-skilled responders were unavailable. Doyle's report recommended the service had to better manage performance, to periodically review distribution of staff and aircraft and to regularly review a sample of air ambulance dispatch decisions to ensure resources are allocated with due consideration for patient needs.

ALBERTA

Shock Trauma Air Rescue Society (STARS) has operated in Alberta since 1985. During that time, it has transported thousands of patients with no critical incident reviews.

FUNDING: The Alberta government provides only 20 per cent of the cost, with the non-profit agency making up the rest through sponsorships and fundraising.

In an 2010 agreement, Alberta Health Services agreed to support STARS and provide funding through to the year 2020. In 2010-11, Alberta Health Services provided $6.34 million. Total AHS funding in 2011-12 was $6.88 million.

Total operating expenses per base is approximately $10 million a year. STARS currently operates a fleet of seven Eurocopter BK117 and one AgustaWestland AW139 helicopters from bases on Calgary, Edmonton and Grande Prairie.

ON BOARD: Two pilots, a nurse experienced in emergency/ICU care, an advanced-life-support paramedic and a referral emergency physician.

SASKATCHEWAN

STARS began service in 2012. There have been no critical incidents.

FUNDING: The Saskatchewan government funded $5 million for STARS in 2011-12, with approximately $10 million annually moving forward. The remainder of the funds will come from STARS fundraising efforts, including contributions from the community and corporate sector. Corporate partners to date are:

Crescent Point Energy, lead and founding donor, $5 million.

Mosaic Potash, $5.5 million toward a hangar, engineering and crew quarters and a helicopter for the Regina base.

PotashCorp supports STARS by making available a helicopter and hangar at the Saskatoon base. The estimated value of these assets is $27 million.

Enbridge -- $500,000.

Enerplus -- $300,000.

Husky Energy -- $250,000.

Rawlco Radio -- $100,000.

Graham Construction -- $25,000.

AHEAD: Recently, STARS started landing at Regina General Hospital with Transport Canada's certification of a new, provincially funded $3.4-million rooftop heliport for use. A similar helipad is planned for the new Children's Hospital in Saskatoon.

ONTARIO

Ornge is the publicly funded ambulance service, which includes helicopter ambulance locations across the province. Ornge is responsible for all aspects of the province's air ambulance system, including performing inter-facility transfers, scene calls and non-urgent transfers.

FUNDING: The entire service receives about $150 million annually from the province. Ornge has also been under fire for more than a year over executive salaries and alleged spending irregularities. It fell under public scrutiny after the release of the auditor general's report in March 2011 and is currently the subject of a legislative committee review and an Ontario Provincial Police criminal investigation.

ON BOARD: Two pilots and two paramedics; the level of care required for a given patient determines the level of paramedic assigned to the transport: primary-care paramedics, advanced-care paramedics and critical-care paramedics.

AHEAD: Ornge's service has never been suspended. Ornge reports critical incidents or adverse events to the ministry of health, which has the authority to conduct investigations through its Emergency Health Services Branch.

As a result of a number of these investigations, the Office of the Chief Coroner undertook a review of air ambulance transport-related deaths in Ontario in 2012 under its Patient Safety Review Committee.

It looked at 40 cases and whether operational issues related to the air ambulance transport may have caused or contributed to any deaths between Jan. 1, 2006 and June 30, 2012.

The review found in five cases there was a possible impact; in one there was probable impact; and in two cases there was a direct impact.

The focus of the review was on systemic issues rather than the medical care provided by paramedics. However, there were three cases it said blurred the distinction between systemic and individual issues. These cases related to oxygen and ventilation equipment and management of oxygen reserves.

The two direct-impact cases are:

Case No. 1 -- A 17-year-old male with a history of depression was found by his mother with a self-inflicted shotgun wound to his face. He was stabilized at a community hospital in northern Ontario and transported to a community hospital in another province via air ambulance. Prior to transport, he was intubated, though with difficulty, due to the shotgun injuries to the face. During the transfer, the patient became agitated and removed his medical therapeutic airway. This self-extubation was followed by a failure to re-intubate, profound lack of oxygen and a cardiac arrest that lasted 25 minutes with ongoing resuscitation efforts. The patient was resuscitated with return of pulse, but he subsequently died. The review found a delay in co-ordinating the patient's transfer and a lack of effective sedation led to a circumstance where the extubation could occur, which ultimately had a definite impact on the death.

Case No. 2 -- A 22-year-old male had a history of drug and alcohol misuse, diabetes, and acute alcoholic pancreatitis. After bloody vomiting followed a two-day drinking binge, he arrived at the local First Nations nursing station. He was treated and sent home. He returned the next day with worsening symptoms. He was transported via air ambulance to a community hospital in northern Ontario.

The patient required more extensive care than could be provided there, and arrangements were made to transfer him by air to a centre in eastern Ontario. Staffing configuration for the flight was non-standard because of the sudden illness of a critical-care paramedic during the call. A nurse from the intensive-care unit of the sending hospital had to step in. During the transport, the oxygen flow rate was set at 25 litres per minute (L/min) instead of the typical 15L/min. This resulted in the medical oxygen supply running out before landing, at which time vital signs were absent. Resuscitation, including CPR, was initiated, and oxygen from the ground ambulance was provided. Resuscitation efforts continued, but the patient was pronounced dead shortly after arrival in hospital. The review found the non-standard staffing configuration and the accompanying registered nurse's lack of familiarity with the equipment and aircraft may have contributed to the potential for the error in oxygen flow rate setting.

QUEBEC

AirMédic Air Ambulance is a private, membership-based company independent from the public health-care system. It was formed in May 2012 and operates from seven bases in Quebec to airlift members in need of rapid hospital care. It also operates two fixed-winged Pilatus aircraft. AirMédic has never been the subject of a critical incident review.

ON BOARD: Crew includes a pilot, a nurse and a flight paramedic. Aircraft crews assigned to inter-hospital transfers include a pilot, a co-pilot and two flight nurses.

FUNDING: AirMédic is not funded by the Quebec government. Annual individual coverage starts at $120 and family memberships are $250. Members also include remote lodges, the Quebec Major Junior Hockey League and La Capitale General Insurance, which provides its clients with coverage. Services are free of charge for its members. Its structure is similar to Swiss Air-Rescue Rega in Switzerland, which has operated since 1952.

AHEAD: AirMédic plans to open an eighth base shortly. It's currently based in Saguenay, Quebec City, Mont-Tremblant, Saint-Hubert, Chibougamau, Sherbrooke and Radisson.

NOVA SCOTIA

Emergency Health Services LifeFlight is the smallest helicopter air ambulance service in Canada for emergency patient and intra-hospital transport. Canadian Helicopters is contracted by the province to operate a single helicopter base. The service has operated since 1996 and serves more than one million Nova Scotians. Prince Edward Island and New Brunswick also contract this service. At one time, Nova Scotia had a contract with the STARS service, but terminated it in 2001 over discomfort with the fundraising model and the desire to bring the air-ambulance service under the province's umbrella. EHS LifeFlight has never been subject to a critical incident review or suspended because of a death or review.

ON BOARD: A critical-care registered nurse and a critical-care paramedic and two pilots.

FUNDING: The program is fully funded by the province's Department of Health and Wellness. The department's total budget for 2011-12 was $3.76 billion of which the EHS budget was 2.9 per cent or $108 million. Approximately 80 per cent is for paramedic, nurse, physician and other health professionals salaries. The remaining 20 per cent covers operational costs.

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